metabolic stress knh 413. response to stress - nutrition therapy balance between prevention of pem...
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Metabolic Stress
KNH 413
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Response to Stress - Nutrition Therapy
Balance between prevention of PEM and complications of nutrition supportConcerns with protein status and covering that with
calories neededBed weight measurementsVisceral protein status (albumin/prealbumin) **Indirect calorimetry= gold standard
If can’t do that, ~15-35 calories/kilo
Consider status prior to illness, level of injury, current metabolic changes
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Response to Stress - Nutrition Therapy
AssessmentMany standard measures not valid or reliable
Harris-Benedict/Mifflin is good starting point Kcals/kilo is better (25-35 cal/kilo)
Gold standard= indirect calorimetry
Family members important source of informationMeasured weight and visceral protein status may be
affected by fluid balance Indirect calorimetry most accurate for estimating
energy requirementsHyperglycermia is a concern:
Would need to look at artificially supporting with external source of insulin
Overfeeding is a concern: Edema
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Response to Stress - Nutrition Therapy
Assessment Energy estimates – equations
Mifflin-St. Jeor or Harris-Benedict (good starting point) Use stress and injury factors Initial caloric goals: 25-35 kcal/kg
Protein **1.2-1.5 g protein/kg=gold standard Want as high as possible with amount of fluids allowed
“Permissive underfeeding” 14 kcal/kg, 1.2 g protein/kg
Feeding a small amount to keep the gut functioning/flowing
IV solution is an alternate route *Telltale sign for permissive feeding/that pt is not
tolerating a tube feeding: no output, residuals, diarrhea, N/V
Avoiding a hyperglycemia effect
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Response to Stress - Nutrition Therapy
InterventionsOral preferred route
Early initiation of nutrition support with specific dg
First consider enteral
Specialty formulas available
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Response to Stress - Nutrition Therapy
InterventionsSupplemental nutrients to consider:
Arginine, glutamine Branched-chain amino acids: isoleucine, leucine, valine Omega-3 fatty acids Modify type of lipid; menhaden oil, marine oil, structured
lipids Sources of fiber Probiotics, prebiotics, synbiotics
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Response to Stress - Nutrition Therapy
InterventionsComplications of enteral include
Hyperglycemia
Electrolyte imbalances
Aspiration
Mechanical complications
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Response to Stress - Nutrition Therapy
Interventions
Total parenteral nutrition (TPN)
Reserved for NPO status, if enteral access not viable or unable to meet needs (volume)
Hyperglycemia most critical concern Other concerns: catheter occlusion, infection,
hyprtriglyceridemia, intestinal atrophy, electrolyte disturbances, refeeding syndrome
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Burns
Tissue injury caused by exposure to heat, chemicals, radiation, or electricity
Depth of wound and body surface are used to classifySuperficialSuperficial partial thicknessDeep partial thicknessFull thickness
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Burns
Nutrition Therapy/ Implications20% body protein can be lost
Fluid imbalance, pain, immobility
Wound healing requires optimum nutrition
Weight fluctuations
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Burns
Nutrition Therapy/ AssessmentEstimate energy using indirect calorimetry Curreri equation can be used at peak of
burn injuryNeeds do not increase beyond 50-60% total body
surface area burn
Mifflin-St. Jeor equation with injury factor 1.3-1.5
Energy needs increase with fever, infection, sepsis
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Burns
Nutrition Therapy/ AssessmentProtein 1.5-2 g protein/kg
Negative nitrogen balance may not be totally prevented
Set goal to minimize losses and promote wound healing
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Burns
Nutrition Therapy/ InterventionsNutrition support – enteral
Early feeding associated with prevention of infections
Focus on higher protein (20-25% of kcal)
Supplemental arginine, glutamine, omega-3 fatty acids
PN if enteral cannot meet needs
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BurnsNutrition Therapy/ Interventions
Nutrition support - PN Avoid overfeeding, control hyperglycemia
Additional vitamins, minerals, trace elements Vitamins C, A, E, zinc routinely used
Wean from nutrition support when pt. can meet at least 60% of needs orally
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